The study investigated the care provided to patients with acute kidney damage requiring outpatient dialysis after leaving the hospital, comparing it to the care received by patients with end-stage kidney disease, a more common condition. While patients with end-stage kidney disease typically require lifelong dialysis or a kidney transplant, some with acute kidney injury have the potential to recover. This condition can be triggered by factors such as acute infections, shock, reduced blood flow to the kidneys, major surgeries, and kidney-toxic chemotherapy agents.
The study included data from 1,754 patients with acute kidney injury and 6,197 patients with end-stage kidney disease at outpatient dialysis centers. Interestingly, despite lab tests suggesting that acute kidney injury patients might need less dialysis, both groups received similar treatment. Both were started on thrice-weekly dialysis, and most patients in both groups were not assessed for kidney functioning in the first month of treatment.
“For those who have the potential to recover, remaining on dialysis may place them at unnecessary risk for heart disease, infection, organ damage and death,” stated first author Ian E. McCoy, MD, of the UCSF Division of Nephrology.
During the three-month study period, 10% of acute kidney injury patients died, primarily due to the conditions that necessitated dialysis. Of the 41% of patients who recovered kidney function, roughly three-quarters were able to discontinue dialysis without changes in the dose, frequency, or duration. This implies that some patients might have been able to stop dialysis sooner, potentially avoiding unnecessary treatment.
In the worst-case scenario, a patient who could have recovered enough kidney function to stop dialysis may have remained on it. Repeated dialysis sessions can lead to drops in blood pressure, further harming already vulnerable kidneys and driving kidney function below the threshold required for recovery. This highlights the importance of individualized care and monitoring for patients with acute kidney injury, as their outcomes may differ significantly from those with end-stage kidney disease.
“More research is needed on safe weaning strategies,” stated McCoy. “If a patient is weaned off too quickly, they could become short of breath, or they could develop c that can increase the risk of dangerous heart rhythms.”
“On the other hand, continuing dialysis unnecessarily is also risky, since patients experience high rates of heart disease, infection and mortality,” he said.
Incentives and Disincentives in Dialysis Care: The Challenge of Weaning Patients Off Dialysis, according to McCoy. “Deprescribing benefits the health care system, but not the dialysis provider, who will have an empty chair that is not easy to fill. At the same time, kidney specialists lose a multidisciplinary support team of nurses, dieticians and social workers when a patient recovers enough to discontinue dialysis.”
“Kidney specialists are also paid less by insurance for non-dialysis care even though managing a patient with borderline kidney function is more time-consuming and riskier than managing them on thrice-weekly dialysis. For these reasons, the default path of least resistance may be to continue dialysis.”
Study Reveals Ambiguity for Half of Dialysis Patients, Notes UCSF Nephrology Chief Chi-yuan Hsu. “After about three months of dialysis, they almost always are treated like they will remain on dialysis indefinitely,” he said.
“Doctors don’t seem to pay as much attention as they can to monitoring for early, subtle signs of recovery. When someone’s kidney function is at 30%, it’s obvious that they do not need dialysis, but when it’s subtle, it requires skill, attention, careful discussion with the patient and willingness to assume some risk in the weaning process,” stated Hsu. “We suspect many doctors stop dialysis only when the signs are blindingly obvious.”
“The worst-case scenario is a patient who may have recovered just enough kidney function to wean but has remained on dialysis. Drops in blood pressure with repeated dialysis may further inflict damage to the vulnerable kidneys driving kidney function below the threshold believed to be required for weaning,” stated McCoy.
“The patient may now be facing dialysis for the rest of their life or end up needing a transplant, if they are well enough to be a candidate.”
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